潜水军医继续教育训练探讨

目的:改革潜水军医继续教育的教学内容和训练办法,提高潜水医学保障能力。方法:教学中增加基本潜水技术、加压舱安全管理和使用、潜水员心理学、高气压环境下患者的护理技能、潜水疾病治疗和高压氧临床治疗等训练内容。结果:学员可在短期继续教育训练中掌握基本潜水技术,了解潜水员心理学及常用心理疏导办法,掌握潜水疾病患者的护理和治疗。结论:在潜水军医继续教育中增加潜水技术、加压舱使用管理、潜水员心理学、高气压治疗临床实习等教学内容,可增强受训人员的潜水医学保障能力和信心。     

Interpersonal skills training: evaluation in an internal medicine residency.

To determine the effectiveness of teaching interpersonal skills in a general internal medicine residency, a program was developed utilizing videotape feedback of house-staff/patient interactions, a modification of Interpersonal Process Recall (IPR). Fifty-one randomly selected house officers at different levels of training were included in a controlled, pretest-posttest study design. The major pre-post measures were three independent ratings of videotapes of actual first-visit interviews between resident and patient. House officers in the experimental group significantly increased the proportion of each interview devoted to psychosocial issues compared with controls, although the interviews remained predominantly medical; increased the use of effective responses; and improved their level of empathy with patients. Personality and attitude measures were found not to correlate with observed interpersonal skills on pretest or posttest videotapes. House officers rated the training program as being interesting, valuable, relevant, and nonthreatening. The data suggest that interpersonal skills can be effectively taught to internal medicine residents utilizing a videotape feedback training program.     

Physician performance of laboratory tests in self-service facilities. Residents' perceptions and performance

Primary care physicians perform simple laboratory tests in clinical practice, frequently with little formal training. To determine the frequency of tests that are performed and evaluate house officer laboratory skills, we surveyed house officer attitudes and tested their ability to perform four common laboratory tests. We received 193 responses from 254 house officers at one university teaching hospital. While most perceived the need to use ward laboratories (ie, self-service laboratories located on patient care wards), 67% used them infrequently. Barriers included poor laboratory condition, inadequate time, accuracy, and infectious exposure concerns. Twenty-four percent felt they did not know or were unsure if they knew how to perform simple tests. Forty-seven house officers completed the practical examination. Most accurately reported a spun hematocrit and correctly identified white blood cell findings on a blood smear. Only 50% counted 100 cells. Urinary dipstick interpretation was generally acceptable but the microscopic examination was less accurate. Twenty-three percent failed to identify gram-negative rods on a slide with both gram-positive cocci and gram-negative rods. If physicians are to perform selected laboratory tests, these data suggest, at least in one institution, more formal training, practice, and evaluation are necessary to ensure their performance with adequate proficiency.     

Attitudes of house officers toward a hospice on a medical service

A hospice program (HP) was established on the medical service at the Denver Veterans Administration Medical Center (DVAMC) for the care of the terminally ill cancer patients and to integrate such care into house staff training. A two-bed inpatient unit was managed by an intern, a resident, and the attending physician with the aid of a multidisciplinary team. During the program's first year, 29 patients were cared for with an average inpatient stay of 26 days. Twenty-nine out of a possible 33 house officers returned questionnaires evaluating their hospice experience. Twenty-eight respondents felt that the hospice program was appropriate in a teaching hospital. Over half indicated improved awareness of the psychological problems of their patients and families. Two-thirds of the house staff members felt that the HP changed their approach to pain control and made them more comfortable in dealing with terminally ill patients. From this study, it can be concluded that a hospice program can be successfully integrated into an active medical teaching service.     

Medical students in their final six months of training: progress in self-perceived clinical competence, and relationship between experience and confidence in practical skills

INTRODUCTION: We evaluated the progress in the self-perceived competence of medical students in a range of common clinical, practical and personal skills, in their final six months of training. METHODS: The study was conducted on 65 final-year medical students undertaking their senior clerkship training at International Medical University, Malaysia. Questionnaire surveys were conducted at the beginning and the end of the six-month period, with 44 items covering clinical, practical, personal skills and readiness to work. Correlations were performed for experience and self-perceived competence, with the respective skills. RESULTS: 64 students returned the first survey and 63 returned the second survey. When the two survey results were compared, significant increases were found in self-perceived competence for the majority of the skills examined. The items with no significant improvement were divided into those which the students were already proficient in before senior clerkship, and those in which experience and confidence remained poor at the end of training. There were significant, but moderate, correlations between the experience and confidence of all common practical skills (correlation coefficients: 0.348-0.522, p-value is less than 0.001 for all items). At the end of training, students were, in general, more prepared to work as house officers (mean rating in the first survey: 3.05, second survey: 3.97, p-value is less than 0.001). CONCLUSION: Significant progresses in clinical experience and confidence can be observed in the final stages of medical training. The findings of inadequate improvements in some skills call for dedicated training sessions and strengthening of on-site supervision.     

Introducing quality assurance and medical audit into the UCSF medical center curriculum.

The experience gained by a medical school faculty in developing and piloting a course for undergraduate medical students in medical care evaluation led to a similar effort for house staff. It is recognized that if the profession is to fulfill the demand by society for social accountability in the use of resources for health care, medical care assessment and quality assurance mechanisms must become an intimate part of the clinical experience of medical students and house officers. Teaching these subjects requires a theoretical framework; introduction of content and skills appropriate to the level of the student and continuation of progressively more advanced training throughout medical education; use of assessment and quality assurance techniques by clinician-teachers themselves to provide models for the student; and continued evolution of pedagogic approach and course content based on developments in the area.     

A randomized trial of ethics education for medical house officers.

We report the results of a randomized trial to assess the impact of an innovative ethics curriculum on the knowledge and confidence of 85 medical house officers in a university hospital programme, as well as their responses to a simulated clinical case. Twenty-five per cent of the house officers received a lecture series (Limited Intervention or LI), 25 per cent received lectures and case conferences, with an ethicist in attendance (Extensive Intervention or EI), and 50 per cent served as controls. A post-intervention questionnaire was administered. Knowledge scores did not differ among the groups. Confidence regarding ethical issues was significantly greater in the aggregate intervention group (3.9 on a 1 to 5 scale) compared to the control group (3.6). Confidence regarding procedural issues related to ethics was significantly higher for the EI group than for the controls (4.0 v 2.8). Responses to a simulated case showed that significantly fewer house officers in the EI group would intubate a patient for whom such therapy would be futile (EI = 57 per cent, LI = 87 per cent, Controls = 82 per cent). We conclude that ethics education can have an impact on house officers' confidence and their responses to a simulated case, and that the EI was more effective than the LI. Such results have implications regarding the implementation of ethics education during residency.     

An appraisal of goals for residency training in internal medicine

The goals for residency training in internal medicine were assessed by faculty and house staff members at one university-based program using a 38-item questionnaire based largely upon American Board of Internal Medicine criteria. The respondents rated each item according to its ideal importance, its actual emphasis in training, and the respondents' degree of satisfaction with their own level of accomplishment for that item. Faculty and house staff members shared similar perceptions of ideal goals and actual emphases of training, with both groups rating clinical judgment, gathering data, and formulating problems as the most important. Both groups also tended to rate highly as ideal goals those items that they considered to be their own professional strengths and that reflected their current respective roles in medical training. This trend was the most apparent for faculty members in ratings of academic skills and for house staff members in ratings of technical proficiency and patient management skills. The tendency to idealize one's own professional role and strengths may inhibit needed changes in residency training.     

A senior-year experience similar to an internship.

A senior year experience similar to an internship was initiated in community hospitals. It is designed to shorten the overall length of training and to restore a broad-based clinical experience to the period of "intermediate patient care responsibility" in the training of new physicians. The program provides students with an opportunity to observe and practice in a primary care setting and expands the clinical resources of the medical school. Analysis of the performance of students in the class of 1974 indicates that they perform on a level comparable with first-year house officers. This program provides a general clinical experience for those students who have not yet decided on future training plans or who are going into primary care fields.     

The development of an education program in the pediatric emergency department.

The pediatric emergency department is a major educational resource in ambulatory pediatrics. A literature review indicates a lack of programs based on the identification of specific educational objectives in this setting. A model educational program for third-year pediatric clinical clerks and pediatric level I and II house officers is presented. Learning is defined in three areas: patient management, behavioral care needs, and hospital and community health care needs. Information on specific educational goals and objectives, learning experiences derived from them, and methods for evaluation of learning is provided.     

Survey of junior hospital doctors' attitudes to cardiopulmonary resuscitation

Most cardiac arrest teams are made up of junior doctors. The stressful effect of cardiopulmonary resuscitation (CPR) on doctors has not previously been established. A questionnaire was sent to all 52 junior doctors who participated in the cardiac arrest team at a district general hospital. Forty one questionnaires were returned by 22 junior house officers, 12 senior house officers, and seven specialist registrars. The questionnaire was anonymous so non-responders could not be recontacted. Seventy three per cent found CPR stressful. The main reason for stress was the inappropriateness of CPR on the individual patient (12), poor outcome (13), no advanced life support (ALS) course (4), and the procedure itself (4). Fifty four per cent felt the number of inappropriate CPR had increased in the last six months with the main reason given (48%) being failure of senior staff to make "do not resuscitate" orders. Ninety seven per cent felt some CPRs were inappropriate; 70% felt a debriefing session should occur after CPR, while 88% reported not having one. Seventy six per cent felt competent at performing CPR, 22% felt incompetent of whom none had undergone ALS training. Fifty eight per cent found it difficult to discuss CPR with patients; 46% found it difficult to discuss CPR with relatives. Most junior doctors feel stress from CPR. Adequate review by senior doctors with documentation of do not resuscitate orders where appropriate, after discussion with patients, might be beneficial. Adequate training, improving communication skills, and support for junior doctors in the cardiac arrest team need to be reviewed since improvement in these areas may reduce stress.     

Skills of medical students and house officers in prescribing narcotic medications

Eighty-eight medical students and house officers were given patient management questions to assess their ability to convert from one narcotic regimen to an approximately equal analgesic dose of a second regimen. Only 8 percent of their answers were within the correct range, even though commonly used reference material was supplied to assist them in answering the questions. There were no significant differences in the responses of house officers from different medical specialties or among all the individuals at different educational levels. Correct answers to the patient management questions markedly increased after instruction on the use of a narcotic equivalency table. More emphasis on the importance of adequate pain control, better teaching of the pharmacology of narcotic analgesic drugs, and additional instruction on the use of narcotic equivalency tables are needed in medical school and house staff training programs.     

Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism

Although alcoholism is prevalent in both general and inpatient populations, barriers to its timely diagnosis and effective treatment exist. These are often attributed to physicians' inadequate understanding and skill development and negative attitudes toward the disease. All Johns Hopkins' medical students and house staff, during 1986 through 1987, received a self-administered survey of their attitudes, skills, perceived role responsibility, knowledge, and reported practices with regard to alcoholism. Results indicate a strong relationship between perceived role responsibility, confidence in skills, and reported screening and referral practices among students and house staff. Knowledge levels strengthened the association between skills and practices for medical students. House staff perceived less of a responsibility for screening than medical students. There was a trend toward lower confidence and more negative attitudes among house staff than medical students. The results point to areas where educational interventions can be improved to enhance quality of care and outcomes for this major chronic disease.     

Do house officers learn from their mistakes?

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.     

结合救援需求对营区卫生士官掌握战伤救护六大技术的现状调查

目的：了解部队营区卫生士官对战伤救护技能的掌握现状、获取途径及学习需求。方法：采用整群抽样对某军校150名营区卫生士官进行问卷调查,数据处理采用SPSS11.0软件进行。结果：了解六大技术的学生仅占27.3%,也就是说,战时真正能够发挥自救互救作用的人员比例是极低的,20.7%的人对六大技术一无所知或知之甚少,另有52.0%的人理论上学习过,但缺乏实践操作,同样不具备救护能力。结论：部队基层人员对六大技术的普及率仍然比较低,远不能满足突发灾害及未来战争战场自救互救技术的要求。在重点强调战伤救护六大技能的基础上,结合部队实践及实战需求加强培训力度。     

Handbooks, learning contracts, and senior house officers: a collaborative enterprise.

Efforts to bring about improvements in hospital-based education and training for senior house officers over the last few years have raised issues which are gradually being addressed. One of these is the lack of understanding by many clinical teachers of educational principles and their application to senior house officer training. This study describes how volunteer consultants in five specialties in a North West District General Hospital worked together to develop an educational structure for senior house officers. An audit of education and training was carried out across the hospital to help identify problem areas. An education specialist worked with consultants to develop, implement and evaluate a handbook based on adult learning principles. The handbook incorporated a learning contract, formal review process and a curriculum of learning objectives for each specialty. In parallel, consultants created in-house videos which were used to raise awareness of clinical teachers in the hospital about these educational issues. Preliminary evaluation showed positive responses by both senior house officers and consultants to both the study and its outcomes.     

Sources of resistance to an intern support group

When senior house officers were observed to be resistant to an intern support group, they were surveyed in order to identify the sources of their resistance. Sixty-nine percent of house officers in postgraduate year two (PGY-2) and PGY-3 responded to an anonymous seven-item survey. Although their attitudes toward supportive programs were generally favorable, a minority of the house officers felt that residents expressing the need for support were less competent than other residents or needed to change to a less rigorous specialty. A majority felt that it was unfair to require senior house officers to provide coverage for interns attending a support group. They felt that support should be made available to all house officers rather than interns only and that stress would be reduced by eliminating the sources of stress as well as by providing supportive programs. Training program directors need to be aware of and anticipate these attitudes before designing supportive programs.     

What Makes a Good Doctor?

Introduction In the United States and I suspect in all parts of the world, a good doctor is an individual who, in addition to training in their area of interest, i.e., family practice, internal medicine, or a subspecialty area, has participated actively in the educational programs relating to their training which make them eligible to take examinations in those areas (if they are available) and pass them.All physicians generally like to have some procedural skills,but the most important part of their skills relate to their cognitive knowledge which in the long term insures optimal patient care.     

Training in a primary care internal medicine residency program. The first ten years

We surveyed all 49 graduates of the University of California, San Francisco, residency program in primary care internal medicine to determine whether they chose careers as general internists and whether training in ambulatory care at the expense of hospital-based medicine is adequate preparation for general internal medicine practice. Graduates rated adequacy of training and relevance to their current clinical practice of 87 content and skill areas on five-point Likert scales. Of the 44 respondents, 39 (89%) chose careers as general internists and five (11%) as subspecialty internists. Training in nine of 11 internal medicine disciplines (eg, cardiology) was rated as highly adequate, and the areas as highly relevant. For ten of 15 non-internal medicine areas (eg, ear, nose, and throat), mean relevance scores significantly exceeded adequacy scores, suggesting training underemphasis. Mean relevance scores also significantly exceeded adequacy scores for seven of 11 basic knowledge/skill areas (eg, patient interviewing) and 13 of 14 areas related to clinical practice (eg, quality assurance). We conclude that the vast majority of graduates of the University of California, San Francisco, primary care residency program became general internists and that, rather than feeling deficient in training in hospital-based medicine, graduates reported unmet needs for ambulatory-care experiences and skills related to general internal medicine practice.     

Practice nurses and antismoking education

A questionnaire on antismoking activities and education was sent to 369 nurses in general practice. The response rate was 80%. Although most of the nurses sometimes advised patients about smoking, routine antismoking education occurred less frequently. Only a few regularly referred smokers to other agencies for help, recommended aids to stop smoking, or used antismoking literature. Although the nurses thought that they had an important role in helping smokers to give up, they expressed little confidence in their effectiveness, believing that advice from the general practitioner and the smoker's personal determination to give up have more impact. The nurses expressed a need for training in antismoking education. Seventy seven per cent were interested in attending seminars and listed information about smoking, techniques for stopping, and counselling skills as priorities. If practice nurses are to use opportunities in primary care to help smokers there is clearly a need to provide further training and to establish the effectiveness of nurses in their role as smoking educators.